Popliteal Angle Research Articles

Aponeurotic release of semimembranosus: A technical note to increase correction gained with hamstring lengthening surgery in cerebral palsy.

The aim of this study was to determine the intraoperative corrective effect of the aponeurotic release of semimembranosus (SM) as a single procedure or an adjunct procedure to distal myotendinous release of semitendinosus (ST) and myofascial release of SM lengthening in the correction of knee flexion deformity in cerebral palsy (CP). In this prospective study, 46 knees of 23 consecutive ambulatory patients (15 boys and 8 girls; mean age=8.33 years; age range=5-12 years) with spastic diplegic CP with a gross motor function classification system level (GMFCS) II or III were included. The patients were then divided into 2 groups. In group I, there were 10 patients (4 boys, 6 girls; mean age=8.6±2), and combined release of ST in the myotendinous junction and SM in the myofascial junction, followed by aponeurotic release of SM were carried out. In group II, there were 13 patients (2 girls, 11 boys; mean age=8±2.35), and aponeurotic release of SM was done first and followed by the combined release of ST in the distal myotendinous junction and the myofascial release of SM. Intraoperative popliteal angle (PA) measurements were recorded in each group. PA was reduced from 58.1°±7.6° (range=46°-75°) to 41.2°±8.8° (range=20°-54°) in group 1 and from 59.1°±11.3° (range=40°-87°) to 42.7°±10.8° (range=24°-64°) in group 2. No significant difference was observed between the groups in terms of reduction in PA (p=0.867). In group 1, adding the aponeurotic release of SM further reduced the PA to 31.7°± 8.5° (range=14°-47°) (p=0.002). In group 2, adding the myotendinous release of ST and myofascial release of SM further reduced the PA to 32.9°±7.2° (range=16°-44°) (p=0.004). There was no significant difference between the final PA values in the 2 groups (p=0.662). There was no difference in terms of early complications. Aponeurotic release of SM is equally effective to reduce the intraoperative PA with combined myotendinous release of ST and myofascial release of SM. Combining all the 3 procedures provides a better correction without forceful manipulation or lengthening of the lateral hamstrings during the correction of knee flexion deformity in CP.

Outcomes of Patellar Tendon Imbrication With Distal Femoral Extension Osteotomy for Treatment of Crouch Gait.

Crouch gait is a frequent gait abnormality observed in children with cerebral palsy. Distal femoral extension osteotomy (DFEO) with the tightening of the extensor mechanism is a common treatment strategy to address the pathologic knee flexion contracture and patella alta. The goal of this study was to review the results of a patellar tendon imbrication (PTI) strategy to address quadriceps insufficiency in the setting of children undergoing DFEO. After institutional review board approval, all patients with crouch gait treated at a single institution with DFEO and PTI were identified. Clinical, radiographic, and instrumented gait analysis data were analyzed preoperatively and at 1 year following surgery. Twenty-eight patients (54 extremities) with a diagnosis of cerebral palsy and crouch gait were included. Significant improvements were appreciated in the degree of knee flexion contracture, quadriceps strength, knee extensor lag, and popliteal angle (P<0.01). Knee flexion at initial contact and during mid-stance improved significantly (P<0.0001), and knee moments in late stance were significantly reduced (P<0.01). The anterior pelvic tilt, however, significantly increased postoperatively (P<0.0001). Radiographic improvements were seen in the knee flexion angle and patellar station as assessed by the Koshino Sugimoto Index (P<0.0001). Four patients (14.2%) developed a recurrence of knee flexion contracture requiring further intervention. PTI is a simplified and safe technique to address quadriceps insufficiency when performing DFEO. The short-term results of patients who underwent DFEO with PTI demonstrated improvements in clinical, radiographic, and gait analysis variables of the knee. Investigating long-term outcomes, comparing techniques, and assessing quality of life measures are important next steps in research. Level IV-case series.

Interrater reliability for unilateral and bilateral tests to measure the popliteal angle in children and youth with cerebral palsy

BackgroundShort hamstring muscles can cause several problems for children with cerebral palsy. The results of the clinical measurement of hamstring length are often used in decision-making about treatment of children with cerebral palsy. There are different ways of performing this measurement. The aim of this study was to evaluate the interrater reliability of the unilateral and bilateral measurement of the popliteal angle in children and youth with cerebral palsy.MethodsTwo methods for estimating hamstring length using unilateral and bilateral measurements of the popliteal angle were applied in children with cerebral palsy. Both tests were applied bilaterally by two independent examiners on the same day for each child. The intraclass correlation coefficient (ICC) was calculated to evaluate the interrater reliability of both measurements. Seventy young people with cerebral palsy (32 females, 38 males, mean age 10 years 8 months, range 5–22 years) at Gross Motor Function Classification System levels I (n = 17), II (n = 31), III (n = 12) and IV (n = 10) were included.ResultsThe interrater reliability was good for both measurements. The ICC values were 0.80 on the right and 0.86 on the left for the unilateral popliteal angle, and 0.82 on the right and 0.83 on the left for the bilateral popliteal angle.ConclusionsBoth unilateral and bilateral measurement of the popliteal angle is a reliable method for estimating hamstring length in children and youth with cerebral palsy.

The effect of hamstring tightness on intraoperative extension gap in posterior stabilized total knee arthroplasty

This study aimed to determine the factors related to intraoperative extension gap (EG) in patients who underwent posterior-stabilized total knee arthroplasty (TKA). A total of 106 TKAs in 84 patients were retrospectively reviewed. Only patients who underwent the same method of bone resection were included consecutively. Bilateral popliteal angle (BPA) was used as an indicator of hamstring tightness. EG and extension space angle were measured using an offset type tensor. The associations between patient variables and EG were analyzed using multivariable linear regression and Pearson's correlation coefficients. The average EG was 12.9 ± 2.1 mm, and the average extension space angle was 2.8° ± 3.2°. BPA was greater than flexion contracture in most cases (94.3%), and no difference was found in only six cases (5.7%). According to multivariable linear regression analysis which was conducted after modifying the BPA into a categorical variable by 5°, EG was correlated with BPA (p < 0.001). Pearson’s correlation coefficient between EG and BPA was − 0.674 (p < 0.001). No other factors were significantly correlated with intraoperative EG. The present study found that popliteal angle is a different entity from flexion contracture, and that it is a predictable factor for EG in osteoarthritis patients. Smaller BPAs led to larger EG in patients who underwent the same degree of bone resection.

Relation of serum tumor necrosis factor-α level with disease severity in spastic cerebral palsy

ObjectiveTo detect the relation between serum tumor necrosis factor-α (sTNF-α) level and disease severity in children with lower limb spastic cerebral palsy (CP).BackgroundGlial cells are activated following a primary insult to the immature brain, secreting chemical mediators such as tumor necrosis factor-α, leading to secondary white matter injury, causing CP.Patients and methodsA randomized controlled clinical trial was conducted, including 80 ambulatory children with lower limb spastic CP and 80 healthy age-matched and sex-matched children as control group. At baseline, patients with CP were assessed using Modified Modified Ashworth Scale, bilateral adductor tone score, passive range of motion of lower limb joints, and outcome measures, such as Edinburgh Visual Gait Scale, Gross Motor Functional Measure-88, and Caregiver Priorities and Child Health Index of Life with Disabilities. Interventions were botulinum toxin-A injection, sTNF-α measurement, and rehabilitation. Follow-up after 2, 6, and 12 weeks had the same assessment as baseline, except for sTNF-α, and outcome measures were done at baseline and week 12. The control group had sTNF-α measured.ResultsModified Modified Ashworth Scale, ankle dorsiflexion, popliteal angle, and outcome measures significantly improved after intervention (P > 0.001). Baseline sTNF-α was significantly higher in patients with CP (P > 0.001), positively correlated with CP severity (P = 0.01), and significantly improved after treatment (P > 0.001). Age and weight negatively correlated with baseline sTNF-α. Outcome measures significantly correlated with sTNF-α after intervention.ConclusionBaseline sTNF-α in spastic CP was higher than controls and positively correlated with disease severity. It significantly improved after rehabilitation and significantly correlated with improvement in all outcome measures.

Comparing the effect of static, ballistic and contract-relax stretching on hamstring muscles flexibility in young individuals

Muscular flexibility is an important aspect of normal human function. Sedentary individuals are susceptible to inflexible or reconditioned hamstrings. The tightness of hamstring muscles is one of the main factors hindering performance in daily and sporting activities. A variety of stretching techniques exist to enhance flexibility and range of motion. With the questions regarding the effective gains of different stretching methods, this interventional study was conducted to compare the effect of static, ballistic and contract-relax stretching on hamstring muscles flexibility in young individuals. 90 young, healthy individuals were assessed for the inclusion and exclusion criteria and randomly divided into 3 groups. Group A received static stretching, Group B received dynamic stretching and Group C received contract-relax stretching for hamstring muscles. Sit and reach test (SRT) and popliteal angle (PA) test were used as a standard outcome measures to measure pre and post intervention flexibility of hamstring immediately following the stretch. The result showed statistically significant improvement in SRT and PA concluding that all the three stretching techniques were effective in improving hamstring flexibility in young individuals. Specifically the contract relax stretching was more effective than static and ballistic stretching.

Immediate Effects of Myofascial Release Technique on Muscle Flexibility, Vertical Jump Height in Recreational Badminton Players

Introduction: In the life of a normal human function or in doing activity of daily living muscular flexibility plays an important role. Flexibility is the ability of a joint or series of joints to move through an unrestricted, pain free range of motion. A limitation in the muscular flexibility leads to several musculoskeletal overuse injuries in players life and remarkably affect a person’s level of function. Myofascial Release (MFR) is a manual soft tissue technique that is frequently used in physical therapy for the flexibility purpose. Aim: To find out the immediate effects of MFR on muscle flexibility, vertical jump height in recreational badminton players. Materials and Methods: This was a case control study design with total of 60 recreational badminton players were recruited for the study during July 2018 to May 2019 for 10 months. All the subject was assigned into three groups as per the selected muscle like quadriceps, hamstring and calf muscle. Vertical jump height Knee flexion angle Popliteal Angle (PA) distance from the wall (Lunge test) was measured pre-intervention and post intervention. MFR technique was applied as an intervention. Paired sample t test was used to find out the immediate effect. Results: Quadriceps and hamstring play a significant effect in vertical jump height and the flexibility of the muscles increases after the administration of MFR. Vertical jump height for quadriceps group (p&lt;0.029) showed extremely significant improvement. Flexibility of quadriceps (p&lt;0.001), hamstring (p&lt;0.001) and calf (p&lt;0.001) also showed significant differences. Conclusion: The study concluded that MFR has immediate effect on increasing muscle flexibility and muscle power.

Compare The Effectiveness of Dynamic Stretching with Conventional Stretching on Hamstring Flexibility in Patients with Spastic Cerebral Palsy of Aged Between 5-14 Year

Background: Cerebral Palsy is a broad term incorporating permanent, non progressive, and irreversible locomotors and posture abnormalities. This non progressive disease that arose in the growing fetal brain leads to restriction of activities of daily living. Objectives: The objective of this study was to find out the effects of dynamic stretch on flexibility of the hamstring and compare it with conventional stretch in quadriplegic spastic cerebral palsy.&#x0D; Materials and Methods: The data was collected from children aged between 5-14 years from 3 settings. Written informed consent was obtained from the parents to allow their children to participate in the study. Two groups were formed; each group had 18 children. Both groups was getting 10 min moist heating by manual ice pack after that one group was performed dynamic stretching and other group was performed conventional stretching separately in the supervision of certified physiotherapist. Therapy was given for total 20 hours, 30 min a day, 5 times in a week for 8 weeks. These children were assessed by using Goniometer before (pretest) and after (posttest) performing the BOTH STRETCHING of hamstring for two months. The children were assessed for change in flexibility. Popliteal angle was measured by using Goniometer in non-weight bearing position.&#x0D; Results: The improvement of both groups was compared with independent sample t test. The improvement in popliteal angle in left leg was 9.44±5.87 in Group A and 6.33±2.59 in Group B. The improvement in right leg in Group A was 11.11±6.12 and in Group B was 5.28±1.93.&#x0D; Conclusion: Both treatment methods i.e. dynamic stretching and conventional stretching were found to be effective but dynamic stretching is more effective than conventional stretching in improving hamstring flexibility in Children with spastic cerebral palsy.

Assessment of the Relationship between Hamstring Tightness and Pelvic Tilt in Cerebral Palsy: Are We Overdoing Hamstring Releases in Children with Spastic Bilateral CP, GMFCS Level I-III?

In 50 consecutive ambulating purely spastic diplegic children (100 limbs), with a mean age of 6.4 y having bilateral hamstring tightness with a popliteal angle ≥ 50° the Thomas test was done and the popliteal, modified popliteal angle and the hamstring shift were determined. Radiologically, the sacrofemoral angle (SFA) and the lumbar lordosis angel were measured. The correlations between the SFA and hamstring shift, lumbar lordosis angle and hamstring shift and between the SFA and the lumbar lordosis angle were analyzed and the effect of muscle imbalance on these angles was assessed.

Anterior distal femoral hemiepiphysiodesis with and without patellar tendon shortening for fixed knee flexion contractures in children with cerebral palsy.

PurposeSurgery is often required for fixed knee flexion contractures in patients with neuromuscular conditions. Anterior distal femoral hemiepiphysiodesis (ADFH) is an alternative to distal femoral extension osteotomy (DFEO) in skeletally immature patients. ADFH is typically not accompanied by patellar tendon shortening surgery (PTS). Our purpose was to compare ADFH alone versus ADFH with PTS for treatment of fixed knee flexion contractures and crouched gait in children with cerebral palsy (CP).MethodsRetrospective review of pre- and postoperative gait analysis data for children with CP who underwent ADFH alone, or ADFH with PTS. Data were analysed using linear mixed models to control for covariates.ResultsIn total, 25 participants (42 limbs) were included, 17 male and eight female, mean age at surgery 12.9 (sd 1.9) years. Both groups experienced significant improvement in popliteal angle, knee extension range of motion (ROM) and knee extension in stance phase. Greater improvement was seen for all variables in the ADFH/PTS group, mainly due to greater popliteal angle and knee flexion during gait preoperatively in that group (p ≤ 0.02) rather than the procedure performed (p ≥ 0.19). There was no difference between groups postoperatively. Rate of contracture resolution was 0.5° to 1.0° per month, faster in larger contractures (p = 0.02).ConclusionsADFH with and without PTS is effective in improving knee extension in skeletally immature patients with CP, correcting contractures at a rate of 0.5° to 1.0° per month. Combined ADFH and PTS surgery may be preferable in patients with larger contractures of up to 30° to 35°.Level of evidenceIII

Effects of Static and Dynamic Stretching With Strengthening Exercises in Patients With Patellofemoral Pain Who Have Inflexible Hamstrings: A Randomized Controlled Trial.

Patellofemoral pain (PFP) syndrome is closely associated with muscle tightness. However, studies regarding the effects of stretching exercises on PFP patients with inflexible hamstrings are scarce. The aim of the study was to compare the effects between static and dynamic hamstring stretching in patients with PFP who have inflexible hamstrings. Compared with static hamstring stretching, dynamic hamstring stretching will improve the parameters of hamstring flexibility, knee muscle strength, muscle activation time, and clinical outcomes in this patient population. Prospective randomized controlled trial. Level 2. A total of 46 patients (25, static stretching; 21, dynamic stretching) participated. Hamstring flexibility was assessed according to the popliteal angle during active knee extension. Muscle strength and muscle activation time were measured using an isokinetic device. Clinical outcomes were evaluated using the visual analog scale (VAS) for pain and the anterior knee pain scale (AKPS). There were no differences in hamstring flexibility and knee muscle strength of the affected knees between the groups (P > 0.05). Significantly improved muscle activation time and clinical outcomes of the affected knees were observed in the dynamic stretching group compared with the static stretching group (all Ps < 0.01 for hamstring, quadriceps, VAS, and AKPS). In patients with PFP who have inflexible hamstrings, dynamic hamstring stretching with strengthening exercises was superior for improving muscle activation time and clinical outcomes compared with static hamstring stretching with strengthening exercises. Clinicians and therapists could implement dynamic hamstring stretching to improve function and reduce pain in patients with PFP who have inflexible hamstrings.

Muscle strength, muscle power and body composition in college-aged young women and men with Generalized Joint Hypermobility.

The aim of this study was an evaluation of the musculoskeletal system in women and men with Generalized Joint Hypermobility (GJH). The study included 87 participants– 40 with Generalized Joint Hypermobility (aged 21.2 ±1.8 years) and 47 (aged 21.0 ±1.3 years) in the control group (CG). The study included the Beighton score, the measurements of body composition, muscle flexibility (Straight Leg Raise test, Popliteal Angle test, Modified Thomas Test), and the measurements of muscle strength and muscle power. T-test and Mann-Whitney U Test were applied to assess the differences between independent groups. The study showed that there were no significant differences (p>.05) in the assessed body composition and the muscle flexibility between both women and men with GJH and the participants in the CG. Under isokinetic conditions for the non-dominant lower extremity, men from the CG received significantly higher (p = .02) flexion peak torque at 180°/s angular velocity. Women from the CG received a statistically significantly lower (p = .04) F/E ratio at 180°/s velocity. Under isometric conditions for both women and men with GJH, there were no statistically significant differences (p>.05) in the maximum torques in knee extension and flexion compared to the CG. For women and men with GJH, the maximum power in the lower extremities and jumping ability were not significantly different (p>.05) compared to the CG participants. The body composition, muscle flexibility, muscle strength, and muscle power of adults with Generalized Joint Hypermobility did not differ compared to healthy participants. The fact that there are no differences does not exclude the efficacy of strength training in increasing levels of muscle strength and its impact on body posture and proprioception or coordination.

Screw Anterior Distal Femoral Hemiepiphysiodesis in Children With Cerebral Palsy and Knee Flexion Contractures: A Retrospective Case-control Study.

In children with cerebral palsy who demonstrate hamstring tightness, increasing attention is being paid to less invasive methods of correcting knee flexion contractures. Guided growth principles represent one such approach, and in tandem with a serial extension casting protocol, may provide a less invasive method of addressing these contractures. To date, no evidence is available on this combination of procedures. The purpose of this study was to investigate the effectiveness of a combined lengthening/guided growth procedure (hamstring lengthening, percutaneous anterior screw hemiepiphysiodesis, and serial extension casting) in addressing knee flexion contracture, and to compare this approach to hamstring lengthening and serial extension casting alone. Measures from preoperative and postoperative gait analyses were reviewed retrospectively for 10 patients with cerebral palsy who underwent anterior screw hemiepiphysiodesis and hamstring lengthening followed by serial extension casting [anterior epiphysiodesis (AE) group]. These findings were compared with measures from 19 patients with cerebral palsy who underwent hamstring lengthening followed by serial extension casting [no anterior epiphysiodesis (NAE) group]. Postoperative changes in clinical, functional, and kinematic parameters were assessed. Radiographic parameters were also assessed for the AE group. In the AE group, improvements were measured in knee contracture, popliteal angle, peak stance phase knee extension, knee range of motion, and Gait Deviation Index. Similar results were observed in the NAE group. In the AE group, the lateral distal femoral angle increased into extension by 20.9 degrees at an average of 26-month follow-up. Both groups showed an increase in pelvic tilt postoperatively. There were no surgical complications associated with the screw anterior hemiepiphysiodesis. Four patients did have complaints of knee pain, but the pain was attributable to the implants in only one patient. The AE group demonstrated statistically greater postoperative improvement in popliteal angle, knee flexion contracture, and peak knee extension during stance than the NAE group. Both procedures led to improvements in clinical and functional measures, indicating the validity of this approach as a means of correcting flexion contracture that is less invasive and allows immediate weight bearing. Level III-therapeutic study.

Orthopaedic management of knee joint impairment in cerebral palsy: A systematic review and meta-analysis

BackgroundThe optimal management of impaired knee joint function in patients with cerebral palsy (CP) remains a significant and ongoing challenge in paediatric orthopaedic surgery. Research questionWhat are the clinical and functional outcomes after operative and non-operative orthopaedic interventions for knee joint impairment in patients with CP? MethodsThis systematic review and meta-analysis of orthopaedic interventions for the management of knee joint impairment in paediatric CP patients evaluated study-level data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. We performed searches of the following electronic databases from their dates of inception to November 2019: Medline (Ovid), Embase (Ovid) and Pubmed. We extracted mean differences in pre-operative and post-operative measurements for the following outcomes: minimum knee flexion in stance; knee flexion at initial contact; maximum knee flexion in swing; range of motion; popliteal angle; fixed flexion deformity angle; and mean pelvic tilt. ResultsSixty-nine retrospective cohort studies, prospective cohort studies and RCTs comprising 2991 patients were included with 4578 knees analysed. Included studies were of sufficient quality as assessed by the MOOSE checklist. Operative interventions showed significant improvement in knee flexion at initial contact, knee flexion in stance, range of motion, popliteal angle and fixed flexion deformity which were comparable when subgrouped according to operative technique. In contrast, non-operative techniques and botulinum toxin injection did not confer significant improvements. Operative interventions for knee joint impairment led to increased mean pelvic tilt and reduced maximum knee flexion in swing. SignificanceThis review provides strong evidence that operative interventions for the management of knee joint impairment in cerebral palsy patients improve knee kinematics and clinical examination findings.

Photo-Based Range-of-Motion Measurement: Reliability and Concurrent Validity in Children With Cerebral Palsy.

To investigate intrarater and interrater reliability, agreement, and concurrent validity of a smartphone photography-based application compared with a universal goniometer in children with cerebral palsy. Range of motion of hip abduction, popliteal angle, and ankle dorsiflexion was measured with a universal goniometer and a photography-based application in children with cerebral palsy, Gross Motor Function Classification System levels I to V.A 2-way random-effects intraclass correlation coefficients and Bland-Altman plots, standard error of measurement, and smallest detectable change were used for analyses. The application had good to excellent reliability and concurrent validity compared with a universal goniometer, while the large measurement error of both methods suggests that changes of 10° to 23° are needed to be certain that changes over time are not results of measurement error. A photography-based goniometer can be a reliable and valid tool when measuring range of motion in children with cerebral palsy.

SUPRA CONDYLAR FEMORAL EXTENSION OSTEOTOMY WITH PATELLAR TENDON ADVANCEMENT TO TREAT FIXED KNEE FLEXION DEFORMITY IN CROUCHING AMBULATORY ADOLESCENTS WITH CEREBRAL PALSY

Background: Ambulatory cerebral palsy (CP) patients present with different gait patterns because of muscular spasticity and contractures and subsequent limited range of motion leading to loss of their functional abilities. Crouch gait is one of the most common gait pattern in ambulatory children with CP. Aim of the work: The purpose of this study is to evaluate the results of supra condylar femoral extension osteotomy (SCFEO) and patellar tendon advancement (PTA) in the treatment of fixed knee flexion deformity (FKFD) in patients with spastic ambulatory cerebral palsy (CP) to achieve full knee extension and restore an appropriate relationship between quadriceps length and tension in order to maintain knee extension during the stance phase of gait to correct the crouch gait. Patient and Methods: This prospective case series study was done on 20 patients (37 knees); 12 males and 8 females, who had spastic or mixed (mainly spastic) CP and walked with a crouch gait, and who underwent combined SCFEO and PTA along with the context of single event multi-level surgery. Results: The mean Fixed Knee Flexion Angle (FKFA) improved from 24.25o ±11.86o to be 2.25o± 2.25o. The mean knee extension lag improved from 15.8o±5.68o to be 4.2o±1.31o. The mean Gross Motor Function Measurement (GMFM) improved from 53.3 to be 69.1. The mean Koshino Index (KI) improved from 1.54±0.29 to be 1.14±0.12.Conclusion: For crouching adolescents there are 4 questions must be answered: Frist, differentiate between isolated myogenic flexion deformity and combined myogenic-arthrogenic knee flexion deformity. Second, assess isolated myogenic flexion deformity due to hamstring shortening by unilateral popliteal angle test. Third, differentiate between apparent and true hamstring shortening by popliteal shift test; apparent functional hamstring shortening and hamstring lengthening is not indicated. Forth, if the unilateral popliteal angle is positive with negative popliteal shift test, true hamstring shortening is found.

Change in popliteal angle and hamstrings spasticity during childhood in ambulant children with spastic bilateral cerebral palsy. A register-based cohort study

BackgroundMuscle contractures are developing during childhood and may cause extensive problems in gait and every day functioning in children with cerebral palsy (CP). The aim of the present study was to evaluate how the popliteal angle (PA) and hamstrings spasticity change during childhood in walking children with spastic bilateral CP.MethodsThe present study was a longitudinal register-based cohort study including 419 children (1–15 years of age) with spastic bilateral CP, gross motor function classification system (GMFCS) level I, II and III included in the Norwegian CP Follow-up Program (CPOP). From 2006 to 2018 a total of 2193 tests were performed. The children were tested by trained physiotherapists yearly or every second year, depending on GMFCS level and age. The PA and the hamstrings spasticity (Modified Ashworth scale (MAS)) were measured at every time point. Both legs were included in the analysis.ResultsThere was an increase in PA with age for all three GMFCS levels with significant differences between the levels from 1 up to 8 years of age. At the age of 10 years there was no significant difference between GMFCS level II and III. At the age of 14 years all three GMFCS levels had a mean PA above 40° and there were no significant differences between the groups. The hamstrings spasticity scores for all the three GMFCS levels were at the lower end of the MAS (mean < 1+), however they were significantly different from each other until 8 years of age. The spasticity increased the first four years in all three GMFCS levels, thereafter the level I and II slightly increased, and level III slightly decreased, until the age of 15 years.ConclusionThe present study showed an increasing PA during childhood. There were significantly different PAs between GMFCS level I, II and III up to 8 years of age. At the age of 14 years all levels showed a PA above 40°. The spasticity increased up to 4 years of age, but all the spasticity scores were at the lower end of the MAS during childhood.

Efficacy of robot-assisted gait training combined with botulinum toxin injections in cerebral palsy

Aim: Cerebral palsy (CP) is the most common neuromuscular disorder of the childhood for which various therapeutic modalities available, which range from conservative approach to surgery. In the present study, we aimed to evaluate the efficacy of robot assisted gait training in patients with cerebral palsy following botulinum toxin injections in the lower extremity.Material and Methods: The study enrolled children (4 to 16 years of age) diagnosed with CP presenting to the Physical Therapy outpatient clinic who had level 1 to 4 walking difficulty associated with lower extremity spasticity according to the GMFCS (Gross Motor Function Classification System) and received botulinum toxin injections to the lower extremity within the previous month. CP patients received robot-assisted gait training five times a week over 3 weeks for a total of 15 sessions by two physiotherapists under the supervision of a physician. Study assessments included measurements of the range of motion (ROM) of the joints and the popliteal angle, GMFCS-88, Berg Balance Scale (BBS) and the and Pediatric Functional Independence Measure (WeeFIM) which were conducted before and after treatment.Results: A total of 14 pediatric patients (8 girls, 6 boys) were included in the study. The mean age of the children was 9.93±3.54 years. A statistically significant reduction in the popliteal angle was found at post-treatment assessments compared to baseline. Berg Balance Scale, WeeFIM and GMFCS-88scores were significantly improved following treatment.Conclusion: Robot-assisted gait training following botulinum toxin injections were found to provide marked improvements in motor functions, balance, spasticity and functional status in children with CP.

Comparative Effects of High vs Low Frequency of Static Stretching on Hamstring Flexibility in Diplegic Cerebral Palsy Children

ABSTRACT Background: Cerebral Palsy is the disorder of movement due to brain injury and it comes with spasticity as well. Spasticity is well managed by stretching exercises. This study was a pre-post analysis of the effects of high frequency over low frequency of sustained stretching of hamstring muscle and how it decreases popliteal angle in diplegic cerebral palsy children. Objectives: To determine the effects of high frequency of static sustained stretching over low frequency on hamstring flexibility on children with Spastic diplegic Cerebral Palsy and also to determine if the high frequency of stretches would decrease the popliteal angle significantly. Methodology: Quasi Experimental with pre-post design was conducted in Rising Sun Institute for Special Children, Mughal Pura Campus and Defense campus Lahore for 4 months from December 4, 2015 to April 4, 2016.A group of 32 male children aged 6-12 were treated with higher frequency of static sustained stretching i.e. 6 reps 60 seconds hold 5 days per week as compared to previously given lower frequency of stretching exercise i.e. 3 reps for 30 seconds 5/days/week. The baseline measurements were taken before applying the higher frequency of static sustained stretching and post interventional measurements were taken after four months. Data was analyzed using SPSS version 22.0. The main outcome measure was popliteal angle and increase in hamstring flexibility. Results: Out of 31 patients, 100% were males with the mean age of 8.32±1.77 years. Statistical analysis concluded that high frequency of stretching i.e. 6 reps 60 seconds 5 days/week had significant effect over low frequency i.e. 3 reps 30 seconds 5 days/week on decreasing popliteal angle and increasing hamstring flexibility. P value < 0.05 was taken as having significant effect on study. Conclusion: The study demonstrated that Sustained stretching of high frequency is more significantly effective over low frequency in increasing hamstring flexibility by decreasing popliteal angle in children with spastic diplegic cerebral palsy. Keywords: Cerebral palsy; Range of Motion; Rehabilitation; Static Stretching

Postanesthesia alternation of lower limb contractures in children with spastic cerebral palsy.

The aim of this study was to clarify the effects of general anesthesia (GA) on joint range of motion (ROM) in children with spastic cerebral palsy (SCP). Eighty-four SCP cases (mean age 8.4 years) admitted for first corrective surgery were retrospectively reviewed. Lower limb ROM were measured 1 day before operation and immediately after GA. Contracture of hip, knee, and ankle joints decreased significantly after GA, with + 11.1° (39.5%) for the hip abduction angle, -3.7° (18.0%) for the Thomas test, -15.0° (19.1%) for the popliteal angle, + 6.6° (39.8%) and 7.0° (109%) for ankle dorsiflexion with knee flexion and extension, respectively (all P < 0.001). These changes were correlated positively to pre-GA contracture and body weight, negatively to age, but independent of preoperative functional level, geographic classification of SCP, or modified Ashworth scale. On the basis of these findings, routine post-GA reassessments of joint ROM before corrective surgeries were recommended for pediatric SCP cases.